Difficulty: Medium
Average Score: 76%
Simulated
A 57-year-old client reports, 'I am having the worst headache I have ever experienced.' Which action/Priority should the nurse perform next?
Correct answer
C
Rationale
Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.